What can the maternity investigation deliver?

The news that there is to be an independent investigation by Baroness Amos should be welcomed, but with caution.  Have we been here before?  The Francis Inquiry, the Kirkup inquiry, the Ockenden inquiry, the East Kent inquiry, Nottingham inquiry…the list goes on.  Will this investigation achieve more than the inquiries have done?

In February and March of this year we were involved in a 19 day inquest into the death of Ida.  Ida had died in late 2019 but through obfuscation and delays largely on the part of the Trust, we did not resume the inquest until March 2025.  By that point, there were more than 30,000 pages of disclosure during the course of which there were significant issues identified with the Trust, the governance processes and the clinicians.

It is important to recognise that the NHS, when it works, is a truly remarkable thing.  For millions, it has been the difference between life and death.  We also recognise the restrictions on resources and expertise and that many clinicians, despite these difficulties, provide exceptional care to those in need. However, Ida did not receive the care or treatment that she deserved and neither did her parents.

There were many twists and turns to the chronology but some of the key evidence included:

i. Following the traumatic labour and birth the mother was told that her placenta was observed to be ‘gritty’ and she was asked ‘was she a smoker’, despite it being clear from her medical records  she was a lifelong non-smoker.  Until the conclusion of the inquest the mother was left wondering, did her daughter die because of something she had done?

ii. The family were never told of the ineffectual resuscitation and that pressures on the machine had been turned to a dangerous level.

iii. Following the death of their daughter, the family were told by the Trust that ‘we did everything we could, we couldn’t have done anything else.’

iv. When they requested to speak to the bereavement nurse to try and understand how their daughter had come to die the family were guided onto a delivery suite on the labour ward.  Upon the family expressing their concern they were taken to another room near the day assessment unit, handed the notes and left to review them alone.  They were without guidance and surrounded by women in labour; something that, at best, lacked empathy.

v. They were involved in an HSIB (now MNSI) investigation after which the report concluded there were numerous findings of concern. It is of some note, you may think, that the midwife whose records were found to be inaccurate during the course of that investigation complained about the interview she underwent, although scrutiny of the transcript of the interview discloses only professionalism and courtesy by the MNSI investigators.

vii. The Trusts’ own Root Cause Analysis (RCA) sent to the family failed to identify any substantive failings.  This RCA was the first of 4 with various named lead investigators who, it transpired, had limited involvement in the compilation of the document.  During the course of the inquest the then Ward Manager, now Head of Midwifery told the learned Coroner that she had conducted the investigation although she had no training and the document ‘wasn’t worth the paper it was written on.’  Her evidence to the Coroner was that she had learned a lot through the inquest process; demonstrating the inquest was essential.

viii. There were multiple missed opportunities to identify this incident and refer the matter for further investigation to the CQC, which was described by the Head of Midwifery as a ‘grave failing’.

ix. About 6 months after the death of her daughter the family sent a 7 page letter to the Trust setting out their concerns and requesting a meeting.  There was a meeting with the Clinical Director and the Head of Midwifery and the family were told that ‘there were lapses of care…there are things that we absolutely should have done differently…I’m not going to sit here and make excuses…it wasn’t right and that’s not right.  So what we can do is redo the RCA.’  At that time the family did question the integrity of the RCA if the clinicians intended to amend it simply on their word however they welcomed any further information about how their daughter came to die.

x. Time passed and the family received no further RCA.  Within documentation disclosed to the Coroner there was a document in which it said ‘on reflection the maternity group have concluded that they are not undertaking a further RCA.’

xi. The family had never wanted to involve lawyers.  They did not want litigation.  They simply wanted to understand how their daughter had come to die.

xii. Despite advice from another hospital and the MNSI to report the matter to the Coroner, the Trust did not.  Finally, it was the family’s lawyers who had no other option but to take that step.
Thereafter the stance adopted by the Trust was aggressive, confrontational and obstructive.  Despite their Head of Midwifery and Clinical Director confirming there were lapses of care and the thorough and detailed report from the MNSI (who of course had spoken to the clinicians themselves shortly after Ida’s death) the Trust instructed independent medico legal experts to comment on the case.  They subsequently refused to disclose those reports until ordered by the Coroner.  It is of some note, you might think, that the Coroner said of this:
‘This approach also produced the somewhat surreal situation where the Department of Health, through its arm’s length organisation NHS Resolutions, was obtaining expert reports to disagree with the Secretary of State for Health’s independent panel of experts at the HSIB’.

xiii. The Trust filed a position statement which did not accept the conclusions of their own Clinical Director and Head of Midwifery or the MNSI.  This was amended only 2 weeks before the final hearing, the cynic might think that was a tactical move (some 6 years after Ida had died) to prevent legal representation at the final hearing because with admissions of liability the family would not be able to recover their costs.

xiv. Some of the key issues of the findings of fact and conclusion identified were:
a.    The investigation process was deficient, defensive and reached inadequate conclusions (with the Coroner recording that the Rapid Review and RCA were inadequate).
b.    The midwifery records were inaccurate.
c.    The midwives involved in the care of Ida may not have undergone mandatory training, although this was not clear.
d.    The Head of Clinical Governance said ‘were it not for the HSIB report, the failures in Ida’s care would not have been brought to light by the Trust.’
e.    Dr Kirkup concluded that the RCA ‘report showed nearly all the same features as identified in his 2015 report. Some of the issues highlighted in the 2015 report were that “investigations were flawed, relying upon poor-quality records that conflicted with patients’ and relatives’ accounts“. The report also identified features of investigations as being superficial, protective, brief and failed to identify problems due to a lack of a multidisciplinary approach’. Dr Kirkup said that reports from a midwife, neonatal nurse, obstetricians and paediatricians did not constitute a multidisciplinary approach as this required a discussion and coming to a single overall conclusion. Dr Kirkup also said that an investigation should be inclusive of the family as it was important to hear what they had to say, understand their views and concerns so that any subsequent report answered the questions

xv. At no point did the family receive communication from the Trust to explain the failings in care.

This is just a summary of some of the issues but many, in our experience, are not unusual.  As clinical negligence lawyers who represent families we are endlessly disappointed with the lack of compassion, communication and transparency displayed by Trusts.

It is of note that although this relates to a death which occurred in 2019 the inquest in 2025 illustrated that there had not been any reflection by the Trust as to why their investigation into Ida’s death had fallen short, what had gone wrong and how investigations should be undertaken; it took the coronial process to achieve transparency.

The MNSI in this case shone a light in a dark tunnel of despair for that family.  The only organisation to explain what had happened.  Without the MNSI the family would have been left in the dark.  What is worrying is that the current funding of the MNSI does not appear secure.  As far as we are concerned, this independent organisation is crucial for the safety and wellbeing of pregnant women, women in labour and newborn babies.  Our experience is that they hold a wealth of experience and knowledge that is so very helpful in identifying what has taken place.  Their curiosity is necessary.

It is our opinion that hospitals, as demonstrated by this Trust, are not equipped or able to self-regulate.  To reduce the funding for the MNSI poses a very real risk to those in maternity units and is likely to result in many more serious injuries and deaths.  We can only hope that Baroness Amos takes steps to secure funding for the MNSI to enable them to continue with their vital role.

This article has been written by Sara Sutherland of Exchange Chambers and Anna Mills Morgan of Mackenzie Jones Solicitors.  The views and opinions expressed in this article are our own and do not reflect the official position of any organisation, employer or individual with whom we are affiliated.  All information is provided for general purposes only and should not be taken as professional, legal or financial advice.  While we have taken every effort to ensure accuracy and completeness, we cannot guarantee that the content is free of errors or omissions.  Any reliance you place on the material is at your own discretion.